Modern approaches to
resuscitation seek to bring patient interventions as close as possible to the initial
trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in
resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued
resuscitation with fixed ratios of blood products, the debate about the optimal
resuscitation strategy-especially in austere or challenging environments-is by no means settled. In this narrative review, we give a brief history of military
resuscitation and how whole blood became the mainstay of initial
resuscitation. We then outline the principles of viscoelastic
hemostatic assays as well as their adoption for providing goal-directed blood-component
therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.